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A hypertensive urgency induced by the continuous intake of a herbal remedy containing liquorice

Journal of Human Hypertension volume 20, pages 465–466 (2006)Cite this article

A 67-year-old patient was admitted to our hospital because of a hypertensive urgency. The chronic intake of a herbal remedy containing approximately 10% liquorice root was found to be the triggering agent. With liquorice consumption discontinued, the patient's blood pressure levels fell rapidly and potassium levels normalised. Arterial hypertension was first diagnosed a week earlier when treatment with 5 mg bisoprolol was initiated. Follow-up consultations with his general practitioner revealed continuously elevated blood pressure levels under bisoprolol treatment. Doubling the bisoprolol dose as well as adding acupuncture did not sufficiently lower his blood pressure. On admission, the patient denied that he was using further medications. Right-sided, non-invasive blood pressure, measured on a sitting patient, reached 230/110 mm Hg, with left-sided blood pressure rising to 230/100 mm Hg. Physical examination was normal. Screening for pheochromocytoma and hyperthyroidism was negative. However, a slight hypokalemia at 3.2 mmol/l was noted, possibly hinting at hyperaldosteronism as the underlying cause of hypertension. We stopped bisoprolol treatment and initiated a treatment with the metabolically inactive Ca-channel-blocker amlodipin, aiming to rule out hyperaldosteronism in further tests.

The morning after admission, we saw the patient taking a herbal remedy produced on special demand by Complemedis AG (5012 Schoenenwerd, Switzerland), containing, among other herbs, approximately 10% liquorice root (see Appendix A1 for full content details). The patient took this drug to improve his general well-being and increase his energy levels. It is known that glycyrrhetinic acid, the active substance in liquorice, can produce pseudoaldosteronism by inactivating 11-beta-hydroxysteroid-dehydrogenase and by binding to mineralocorticoid receptors.1 Sigurjonsdottir et al.2 have shown that the full hypertensive effect of liquorice is already reached after 14 days of continuous intake. Additionally, they demonstrated that even doses as little as 75 mg glycyrrhetinic acid consumed daily can cause a significant rise in blood pressure. The patient presented in this clinical vignette had consumed about 180 mg glycyrrhetinic acid daily over a period of 1 year. We diagnosed a liquorice-induced pseudoaldosteronism, leading to arterial hypertension and hypokalemia. With chronic liquorice consumption discontinued, the patient's blood pressure levels under amlodipin therapy fell rapidly to 140/80 mm Hg within 36 h and potassium levels normalised to 3.6 mmol/l. Owing to the negative cardiovascular effects of long-term Ca-channel-blocker administration described by Psaty et al.3 and in the nurses' health study,4 we initiated a treatment with 300 mg irbesartan and 5 mg nebivolol, after having ruled out a primary hyperaldosteronism. Both drugs were tolerated well by the patient.

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Authors and Affiliations

  1. Mount Zimmer Medical Center, Horgen, Switzerland

    T Breidthardt & M Namdar

  2. Klinik im Park, Zurich, Switzerland

    B Hess

Authors
  1. T Breidthardt
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  2. M Namdar
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  3. B Hess
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Corresponding author

Correspondence to T Breidthardt.

Appendix A1

Appendix A1

Full content details of the patient's herbal remedy are given in Table A1.

Table 1 Table a1
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Breidthardt, T., Namdar, M. & Hess, B. A hypertensive urgency induced by the continuous intake of a herbal remedy containing liquorice. J Hum Hypertens 20, 465–466 (2006). https://doi.org/10.1038/sj.jhh.1001997

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